Provider Demographics
NPI:1093877045
Name:GOOD SHEPHERD CENTER
Entity type:Organization
Organization Name:GOOD SHEPHERD CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-335-0020
Mailing Address - Street 1:17314 KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1619
Mailing Address - Country:US
Mailing Address - Phone:708-335-0020
Mailing Address - Fax:708-335-0022
Practice Address - Street 1:17314 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1619
Practice Address - Country:US
Practice Address - Phone:708-335-0020
Practice Address - Fax:708-335-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL008118261QR0400X, 261QD1600X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL16121083OtherBLUE CROSS BLUE SHIELD NO